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Globus pharyngeus : a review of etiology, diagnostics, and treatment

Järvenpää, Pia
2018-08

Järvenpää , P , Arkkila , P & Aaltonen , L-M 2018 , ' Globus pharyngeus : a review of
etiology, diagnostics, and treatment ' , European Archives of Oto-Rhino-Laryngology , vol.
275 , no. 8 , pp. 1945-1953 . https://doi.org/10.1007/s00405-018-5041-1

http://hdl.handle.net/10138/304112
https://doi.org/10.1007/s00405-018-5041-1

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European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953
https://doi.org/10.1007/s00405-018-5041-1

REVIEW ARTICLE

Globus pharyngeus: a review of etiology, diagnostics, and treatment

Pia Järvenpää1   · Perttu Arkkila2 · Leena‑Maija Aaltonen1

Received: 17 April 2018 / Accepted: 14 June 2018 / Published online: 25 June 2018
© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Globus is a non-painful sensation of a lump or a foreign body in the throat, and it frequently improves with eating. Although
globus is a common symptom, only little is known about the etiology, and the causes have remained controversial. Previ-
ously, globus was labelled as a hysterical symptom. However, nowadays, the research has been mainly focused on somatic
causes and it is suspected that the etiology is complex. Because of the unclear etiology, the diagnostics and treatment are
varying, predisposing patients to possible unnecessary investigations. This review presents the current literature of globus:
its etiology, diagnostics, and treatment. In addition, a special aim is to discuss the rational investigation methods in globus
diagnostics and present a diagnostic algorithm based on recent researches.

Keywords  Globus pharyngeus · Globus diagnostics · Etiology · Treatment

Introduction UES pressure and in esophageal motor disorders [7]. Com-

bined esophageal multichannel intraluminal impedance and
Globus (Latin globus = globe), the feeling of a lump in the pH monitoring (MII-pH) distinguishes acid and non-acid
throat, is a general symptom especially affecting women reflux, as well as allows detection of possible proximal
under 50 years. Among apparently healthy adults in a com- reflux, and has the ability to define whether refluxiates are
munity, globus can affect 21.5–46% [1, 2]. The etiology of liquid, gas, or mixed [8]. Moreover, a transnasal esophago-
globus is disputable, leading to disagreement regarding how scopy (TNE) enables a well-tolerated endoscopy to be per-
these patients should be examined and treated. Historically, formed under local anesthesia [9]. Recently, some studies
globus was considered a psychological problem [3]. Cur- have used these new methods to examine the esophageal
rently, it is obvious that the causes are rather multiform, background of globus.
although some patients’ symptoms may have a psychological Common treatment for globus has been to explain the
background. Gastroesophageal reflux disease (GERD), lar- benign nature of the symptom to the patient [10]. An out-
yngopharyngeal reflux (LPR), esophageal motor disorders, patient examination has been suggested to be sufficient in
and improper upper esophageal sphincter (UES) function are patients with typical globus [11]. However, many globus
suggested to cause globus [4–6]. However, studies demon- patients undergo further diagnostics such as radiographic
strating the causal relationship between these disorders and swallowing examinations. It has been proposed that atten-
globus are mainly inadequate. tion and reassurance alleviate globus symptoms, but con-
Currently, methods suitable for investigation of the trary results also exist [12, 13]. Accordingly, some investi-
esophageal etiology of globus are available. High-resolution gations may be performed to exclude a malignancy and to
manometry (HRM) provides more accurate diagnostics on ensure both the patient and the clinician that the symptoms
are harmless.
The aim of this review is to present the literature related
* Pia Järvenpää to globus pharyngeus and to update the current knowledge of
[email protected] its etiology, diagnostics, and treatment. The review discusses
1
Department of Otorhinolaryngology, Head and Neck
the rational investigation methods based on recent research
Surgery, University of Helsinki and Helsinki University and presents an algorithm to guide in globus diagnostics.
Hospital, Helsinki, Finland
2
Department of Gastroenterology, University of Helsinki
and Helsinki University Hospital, Helsinki, Finland

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1946 European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953

Definition and prevalence Laryngopharyngeal reflux

Globus was already recognized in the time of Hippocrates. Laryngopharyngeal reflux (LPR) is considered to be an
Historically, it was considered to be a hysterical symptom extraesophageal indication of reflux disease. In LPR, the
(Greek hystericus = related to uterus), globus hystericus, retrograde flow of gastric contents comes in contact with the
especially affecting anxious women [3]. In 1968, Malcom- mucosa of the upper aerodigestive tract [23]. In contrast to
son observed that not all globus patients were hysterical or esophageal mucosa, the larynx and pharynx are very sensi-
female and suggested use of the term globus pharyngeus tive to gastric reflux, so patients with LPR are more likely
[14]. to have laryngeal symptoms, such as throat cleaning, but do
Overall, globus seems to be equally prevalent in healthy not necessarily have symptoms of GERD, which requires
women and men [15]. However, the symptom affects women frequent and prolonged exposure to reflux [4, 24, 25]. In
age 50 and below three times more than men, and women are addition, it has been proposed that reflux could cause glo-
also more likely to seek medical advice regarding the symp- bus through vagus nerve. This was demonstrated in a study,
tom [15–17]. Globus represents about 4% of new referrals where acid perfusion to the distal esophagus raised the UES
to ear, nose, and throat (ENT) clinics [17, 18]. However, in pressure causing globus sensation [26]. Although hoarse-
one study, up to 78% of patients at other than an ENT clin- ness, cough, and throat cleaning are usually considered to
ics have been found to suffer from globus-like symptoms be LPR symptoms, these symptoms are unspecific and may
measured by the Glasgow–Edinburgh throat scale, but had be caused by other disorders as well [27]. A study by Gooi
never sought health care for those symptoms [19]. et al. found that up to 48% of otolaryngologists considered
LPR to be highly related to globus [6]. However, the pos-
sible connection of globus and LPR has not been clarified.
Etiology The laryngeal findings indicating LPR are also unspecific
and prone to under- and overestimation [28, 29]. Moreover,
Gastroesophageal reflux disease the prevalence of these mucosal findings suggesting reflux
is reported as high as 70% in normal volunteers [30]. There-
Gastroesophageal reflux disease (GERD) is defined as a con- fore, the diagnostic criteria for LPR have not met with uni-
dition in which the reflux of gastric contents causes difficult versal consensus [6].
symptoms and/or complications [20]. The causative role of
GERD in globus is disputable. In 1968, Malcomson was the Abnormal upper esophageal sphincter function
first to connect globus and GERD using barium swallow to
show reflux in over 60% of globus patients [14]. Thereafter, In 1974, Watson and Sullivan investigated globus patients
Cherry et al. demonstrated that 10 patients out of 12 reported and controls with manometry and found that cricopharyn-
globus after acid was supplied to the distal esophagus [21]. geal sphincter pressure was statistically significantly higher
Moreover, GERD was suggested to be a major cause of the in patients with globus [31]. However, Cook et al. found in
symptom in up to 58% of globus patients with abnormal pH their study of 7 globus patients and 13 healthy controls that
results [4]. However, based on an ambulatory pH study, in a globus patients’ resting upper esophageal sphincter (UES)
retrospective setting, findings of GERD were not more com- pressure and its response to stress were normal [32]. In a
mon in patients with globus than in controls [5]. study of 32 globus patients and 24 healthy volunteers, no
In the past decade, the association of globus symptoms statistical difference was found in UES resting pressure [33].
with GERD has been clarified. Globus is now considered Nonetheless, a strong association between hypertonicity of
to be a manifestation of a functional esophageal disorder, the UES and globus in conventional manometry was found
and when a patient has a globus symptom directly related in one retrospective study [5].
to reflux, the patient is considered to have GERD, even if Currently, high-resolution manometry (HRM) is a more
other objective GERD findings are lacking [10]. It has been precise diagnostic method in the evaluation of the esopha-
speculated that globus patients may have non-acid GERD, geal sphincter pressure [7]. Kwiatek et al. used HRM to
which would explain why they do not benefit from PPIs. quantify the timing and magnitude of respiratory variation of
However, a prospective study of Nevalainen et al. indicated the UES and discovered that in globus patients, respiration-
that globus patients without reflux symptoms did not have related change in the resting UES pressure was significantly
acid or non-acid GERD in 24-h MII-pH [22]. Nevertheless, amplified compared to controls and GERD patients, but the
with the use of new advanced investigation methods, it is clinical meaning of that finding is unclear [34]. However,
expected that knowledge of the causative role of GERD as other studies have not found the association between globus
an etiological factor for globus will increase. and elevated UES pressure upon HRM. In one retrospective

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European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953 1947

study, UES basal and residual pressures between globus and study [43]. Middle-aged women with globus were signifi-
dysphagia patients, as well as normal controls, were evalu- cantly more likely to experience neuroticism, to be less
ated. The study showed that mean UES basal and residual extroverted, and to have psychological distress, such as anxi-
pressures were normal in both globus patients and normal ety, low mood, and somatic concerns [18]. Furthermore, up
controls [7]. Moreover, a study by Choi et al. showed that to 96% of globus patients felt more symptoms when a highly
globus patients did not have elevated UES pressure upon emotional state occurred [1].
HRM, compared to normal controls and patients with GERD However, in one Finnish study, globus patients and the
[35]. In addition, a prospective study by Nevalainen et al. general population had a similar prevalence of psychiatric
found that UES pressure was not elevated in globus patients disorders [37]. In addition, in a study by Moser et al., mean
upon HRM [22]. scores were similar for anxiety, depression, hysteria, and
hypochondria in globus patients compared to general medi-
Esophageal motor disorders cal outpatients [44]. In contrary, in a study by Tang et al.,
globus patients in China reported more often psychological
Only a limited number of studies have evaluated esophageal and sleep disorders than controls [2]. Although the symp-
motor disorders as a possible cause or contributing factor tom’s complex causes are accepted, it is still labelled as code
in globus. In 1989, Wilson et al. demonstrated that there F45.8, meaning somatoformic disorder, in the international
were no differences between globus patients’ and controls’ classification of diseases, 10th edition, (ICD-10) [45].
esophageal body motility upon manometry [36]. In another
study, 67% of globus patients’ esophageal manometry was Other causes
abnormal; however, the most frequent finding (29%) was
a nonspecific esophageal motility disorder [37]. In their Conditions causing irritation or inflammation in the phar-
prospective study, Knight et al. evaluated patients with sus- ynx and larynx, such as pharyngitis and postnasal drip, may
pected extraesophageal manifestations of GERD, such as increase local sensitivity and cause globus [46]. In addi-
globus. Upon esophageal manometry, seven globus patients tion, globus may be linked to salivary hypofunction, and
out of 12 had nonspecific esophageal disorders, while two anticholinergic medication causing xerostomia was found to
had a hypertensive lower esophageal sphincter (LES) and be a risk factor for globus in one cross-sectional study [47].
three had normal results [38]. Consequently, the esopha- Anatomical causes, including tongue base hypertrophy and
geal motor disorders most often diagnosed in globus patients a retroverted epiglottis touching the posterior pharyngeal
have been nonspecific and made using conventional manom- wall, have been considered as local factors inducing globus
etry. In 2016, one prospective study used a more accurate [48, 49].
method, HRM, and it revealed an esophageal motor disorder Some studies have investigated thyroid pathology and
in half of the globus patients diagnosed by the Chicago clas- globus. One-third of patients with thyroidal mass experi-
sification, the worldwide accepted algorithmic scheme to enced globus-like symptoms before thyroid surgery [50].
analyze HRM studies [22, 39]. However, these motor disor- In one prospective study, thyroid nodules larger than 3 cm
ders were mainly minor and were similar to those that can located anterior to the trachea were associated with globus
also be detected in healthy subjects [40]. Two of their 21 [51]. However, thyroidal findings, such as nodules, are com-
globus patients had a diagnosis of a major motor disorder: mon coincidence findings in healthy subjects, so their causa-
one with absent peristalsis and one with esophagogastric tive role in globus requires more investigation.
junction outflow obstruction, a subtype of achalasia [22]. In In 2016, a prospective study showed that in 24-h MII-
the future, it is expected that the use of HRM may clarify pH, supragastric belching was diagnosed in globus patients
the possible role of esophageal motor disorders in globus more often than in controls with reflux [22]. Belching is a
patients. However, based on Rome IV criteria if the globus physiological event to release the intragastric air that one
patient has a diagnosis of a major esophageal motor disorder, has swallowed. However, a supragastric belch is generated
the term globus should not be used [41]. when a rapid suction of air into the esophagus is expelled
before it reaches the stomach. Some studies suggest a rela-
Psychological factors and stress tionship between supragastric belching and GERD [52].
Nevertheless, supragastric belching in globus patients is a
Historically, the term globus hystericus was used to suggest novel finding. Different mechanisms for how a supragastric
a psychological origin to the symptom, and in fact, many belch is created have been described. A patient may con-
studies have shown this. In a study by Deary et al., globus tract pharyngeal muscles to draw the air into the esophagus
patients were significantly more depressed than controls or breathe in through a closed glottis [53]. Speech therapy
[42]. Globus patients had also more stress and severe life techniques have been demonstrated to alleviate symptoms in
events throughout the year compared to controls in another patients with supragastric belching [54]. It is possible that

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1948 European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953

some globus patients may contract their pharyngeal muscles an enlarged thyroid, which the ultrasound confirmed to be
inappropriately because of their lump sensation, which may a goiter. Other neck ultrasounds were within normal limits
lead to supragastric belching. In addition, other functional [58].
causes may induce globus sensation. Globus sensation might
be associated to vocal load that can induce voice disorders Videofluorography
[55]. One study showed that some patients with persistent
globus suffered from coexisting voice problems but they did Videofluorography is quite often used in globus diag-
not recognize that themselves [56]. Authors encouraged ask- nostics, although its benefit has not been proven [60]. In
ing for possible voice related problems from globus patients 1982, Ardran examined 300 globus patients with a cinera-
more actively. diographic examination: patients swallowed a fluid barium
To exclude malignancy, many patients undergo further suspension, showing that there was no visible lump in the
investigations. One retrospective study of 699 patients throat [59]. In addition, a modified barium swallow study
showed that typical globus symptoms were not hiding with esophagogram showed no benefit in globus diagnos-
malignancy behind the symptom at the initial visit, whereas tics [61]. Moreover, Luk et al. reviewed barium swallow
five patients with atypical symptoms revealed malignancies pharyngoesophagographies of 908 globus patients and 86%
[11]. In a study by Rowley et al., none of the 74 globus had totally normal results [62]. Authors concluded that
patients developed an upper aerodigestive track malignancy the examination has limited diagnostic value and is, there-
during the 7-year follow-up. However, the study was based fore, not recommended for globus patients; patients under
on a questionnaire, and if a patient noted they were symp- 30 years old, in particular, had no findings. As inline with
tomatic, re-examination was performed [57]. Moreover, in other studies, Järvenpää et al. showed that videofluorography
a study of Järvenpää et al., their national Cancer Registry had no benefit in globus diagnostics [58].
data confirmed that during the 3-year follow-up, none of
the 76 globus patients developed a malignancy in the upper Endoscopy
aerodigestive tract or in the head and neck area, of which
globus could have been an early symptom [58]. Rigid endoscopy has been the gold standard in otorhi-
nolaryngological practice when an endoscopic examination
is needed. However, because it is an invasive investigation, it
Examinations used in globus diagnostics requires general anesthesia and the risk for esophagus perfo-
ration during the diagnostic endoscopic procedure has been
Because the etiology of globus is unclear, uniform inves- reported to be up to 1.2% [63]. Rigid endoscopy has not
tigation strategy is lacking. Taking a careful clinical his- been shown to be useful in globus diagnostics. Nonetheless,
tory is essential to determine whether a patient should be a survey concerning ENT consultants indicated that 61% of
referred for further investigation, such as a radiological respondents used rigid endoscope in globus diagnostics [60].
examination or direct esophagoscopy [59]. However, glo- A retrospective study of 250 globus patients examined with
bus patients without other symptoms are mainly diagnosed rigid endoscopy showed that no malignancies and the status
based on their history and a clinical examination, including of the larynx, pharynx, and upper esophagus were entirely
neck palpation and nasolaryngoscopic examination [10]. normal in 87% [64].
Pathological findings in globus patients can be detected by Transnasal esophagoscopy (TNE) allows examining the
a clinical examination with fiber-optic nasoendoscope [11]. upper aerodigestive tract with a thin endoscope without
Further investigations are not recommended when a patient sedation. Shaker, a gastroenterologist, published the initial
has typical globus [10]. report of TNE in 1994 [65]. However, Aviv et al. were the
first to publish a study of unsedated TNE in a laryngologi-
Neck ultrasound cal practice [66]. The procedure is performed on a sitting
patient, and after a local anesthetic is applied to the nasal
Neck ultrasound is occasionally used in globus diagnos- cavity, the thin endoscope is passed transnasally [67]. TNE
tics. However, studies evaluating its usefulness are lacking. enables examination of the nasopharynx, hypopharynx, and
There are a few studies, which have assessed neck ultrasound larynx before the endoscope is passed into the esophagus,
findings in globus patients, but they have investigated only and a working channel provides an opportunity for taking
thyroid pathology [50, 51]. Järvenpää et al. reviewed the biopsies [67]. TNE has been found to be safe and patients
medical records in their tertiary care ENT clinic of 76 globus tolerate it well [67–70]. Globus is considered to be one of
patients and it revealed that neck ultrasound was performed the indications for TNE [67, 71]. However, in one prospec-
on half of their globus patients [58]. However, it was only tive study, TNE was performed by both an otorhinolaryn-
useful in one patient who already had a palpable finding of gologist and a gastroenterologist together and also included

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European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953 1949

investigation of the stomach and the beginning of the duode- GERD diagnostics require invasive and expensive examina-
num, but the examination showed no benefit in globus diag- tions, empirical PPI therapy to diagnose and treat possible
nostics [22]. In that study, 10% of globus patients had endo- reflux is common. GERD responds well to PPI medication,
scopic esophagitis defined by the LA Classification system but LPR’s response to this medication varies and may require
[22, 72]. However, one study among a normal population higher doses and longer treatment periods [78, 79]. One pro-
without reflux symptoms showed that esophagitis was diag- spective, uncontrolled study demonstrated no changes in gene
nosed in 9.5%, using gastroscopy [73]. Moreover, the biop- expression of cytokines related to inflammation when biopsies
sies, including those from the hypopharynx, did not reveal were taken from the posterior larynx tissue before and after
any additional findings, such as eosinophilic esophagitis in a 10-week therapy of PPI [80]. In addition, a meta-analysis
globus patients, in that sample [22]. Thus, studies have not concluded that using high-dose PPIs are no more effective than
shown that rigid nor flexible endoscopy is useful in globus placebo in the treatment of laryngopharyngeal symptoms pos-
diagnostics. sibly connected to GERD [81]. Moreover, placebo has been
as effective as PPIs in resolving globus symptoms [82, 83].
Manometry When concomitant with disorders such a major depres-
sion or panic disorder, anti-depressants have been beneficial
Previously, a conventional manometry with five-to-eight in resolving the globus symptoms as well, though study sam-
pressure sensors was a standard investigation method used ple sizes were small [84, 85].
when esophageal bolus transit pathology was suspected [74]. Globus patients with a thyroidal mass experienced
However, patients’ symptoms and manometric findings are improvement after thyroid surgery [50]. Moreover, globus
considered to be poorly associated [75]. Currently, HRM patients with an epiglottis touching the posterior wall of the
gives more precise information about an abnormal bolus pharynx became asymptomatic after partial epiglottectomy
transport, esophageal motility disorders, and UES pressure [49]. However, both these studies lacked controls. Conse-
[7, 74], and it has recently been studied in globus diagnostics quently, it is impossible to determine the operations’ pos-
[7, 34, 35]. However, recent findings upon HRM do not con- sible placebo effect as all surgical procedures may, them-
firm the association between globus and elevated UES pres- selves, have a curative effect and spontaneous recovery
sure nor esophageal motor disorders, and therefore, HRM is cannot be excluded completely.
not recommended to be routinely used in globus diagnostics. Reducing laryngopharyngeal tension with neck and
shoulder exercises, and relaxation techniques with voice
pH monitoring and 24‑h multichannel intraluminal hygiene and voice exercises improved 92% of globus
impedance patients’ symptoms in one uncontrolled study [86]. In a
sample of 36 globus patients, a speech and language pathol-
Previously, esophageal pH monitoring was a gold standard ogist (SLP) treated half of the globus patients with exer-
for investigating esophageal reflux events in GERD diag- cises to relieve laryngopharyngeal tension, while controls
nostics [8]. However, it was not able to detect weakly acidic were only given reassurance by a nurse. After 3 months,
or non-acidic reflux. Multichannel intraluminal impedance patients in the SLP group had significant improvement in
(MII) detects all reflux events: liquid, gas, or mixed [8, 76]. their symptoms compared to the control group [12]. How-
Moreover, when MII is combined with pH monitoring, it ever, whether globus patients only benefit from attention,
allows for detection of acid and non-acid reflux episodes and rather than the SLP’s therapy, remains ambiguous. In addi-
for analysing associations between a patient’s symptoms and tion, one prospective study demonstrated that globus patients
MII-pH findings [8, 77]. Recent findings, however, do not experienced recovery from their symptoms during a 4-month
support the association of globus and GERD if patients do follow-up after an ENT physician had investigated them and
not suffer from concomitant heartburn [22]. As MII allows they had undergone some further diagnostic procedures with
detecting aerophagia and supragastric belching, its use in the normal findings [56]. This result suggests that some glo-
future might clarify whether globus and these disorders may bus patients may benefit from assurance of the symptom’s
be connected in some patients [22]. benign nature: however, this should not lead to unreasoned
further examinations.

Treatment
Prognosis
Because the etiology of globus is controversial, there is no
strategy regarding how to treat globus patients. PPI medica- In globus patients, rapid symptom relief is often unlikely.
tion is often prescribed, because it has been suggested that During a long follow-up period of an average of 7.6 years,
globus may be related to GERD and LPR. Because exact 55% became asymptomatic and 45% had persistent

13

1950 European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953

Fig. 1  Diagnostic algorithm for Causality? Palpaon finding

globus patients E.g. Cyst of
Consideraon of in the neck / Neck ultrasound
vallecula
operave treatment goiter
Consultaon of
Problems related phoniatrician / speech
Yes to voice and language
pathologist
Globus
paent’s* Dry mucous Humidificaon of the
Findings in ENT- membranes, thick nose and throat,
mucus drinking enough water
examinaon
No
PPI-medicaon, reflux
*Feeling of a lump or a Heart burn self-care, EG/TNE if
foreign body in the throat, necessary
no dysphagia or pain
Instrucons, contact to
Muscle tension
general praconer
No other
symptoms Instrucons, contact to
Stress
general praconer

Informaon about the Consideraon of

Belching, difficult
symptom’s bening nature EG/TNE and 24 h MII-
symptoms
pH, manometry

ENT=ear, nose and throat, EG=esophagogastroscopy, TNE=transnasal esophagoscopy, PPI=proton pump inhibitor, MII-pH=mulchanel
intraluminal impedance and pH-monitoring

symptoms [57]. In a study with a shorter follow-up, an aver- Neck ultrasound is not useful in globus diagnostics if
age of 27 months, 50% of patients became asymptomatic or neck palpation is normal. In addition, globus patients do
experienced symptom relief [87]. Male gender, short dura- not benefit from videofluorography as they lack swallowing
tion of the globus symptom, and no other throat symptoms difficulties. Currently, new investigation methods, such as
were associated with rapid resolution of symptoms [87]. In HRM and 24-h MII-pH, enable more accurate diagnostics
a study by Järvenpää et al. globus patients received a ques- and further studies will clarify whether supragastric belch-
tionnaire concerning their present symptoms 3 and 6 years ing, aerophagia or major esophageal motor disorders are
after the initial visit at ENT clinic [58]. At both follow-ups, overrepresented in globus patients. This knowledge would
approximately half of the patients reported that they were also enhance the available treatment options, since treat-
asymptomatic or that they had fewer symptoms than at the ment until now has mainly been to give reassurance to the
initial visit [58]. However, almost half of the patients felt patients. However, these new investigations are not recom-
that their symptoms were the same at follow-ups [58]. mended to be used in clinical routine.
Based on the literature, globus patients without alarming
symptoms, such as pain or swallowing difficulties, and who
Discussion have no findings in ENT examination including nasolaryn-
goscopic examination and neck palpation, require no further
The recent literature confirms that not only one cause can examinations. However, analysing patient history carefully
explain a globus patient’s symptoms, but also the back- may reveal a globus patient’s concomitant voice problem,
ground is multifaceted. PPIs have been widely used to treat stress or tension in the neck, and in these cases, the diagnos-
globus, perhaps as a trial to diagnose silent reflux. However, tics and treatment should focus on these issues. Most of the
the current literature does not support the assumption that patients suffer from mild and intermittent globus symptoms
GERD is the main cause for globus. In addition, high-dose and it is known that many patients’ symptoms alleviate with-
PPIs are no more effective than placebo in the treatment of out any treatment. The most important thing is to explain the
globus. As PPIs may have long-term side-effects, the use of patient the symptom’s natural course and advise to contact
this medication requires justification. However, if the patient again if the symptoms become severe or progressive, or if
has concomitant heartburn, the diagnostics and treatment other symptoms such as pain or dysphagia occur.
should direct to GERD.

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European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953 1951

Conclusion patients. A randomised controlled trial. Rev Laryngol Otol Rhinol

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